Practical Anatomy
J. Eric Greensmith, MD, PhD
Associate Professor of Anesthesiology
Chief, Division of Acute Pain Management
M.S. Hershey Medical Center
The Pennsylvania State University
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
Goals:
Correlate functional aspects of anatomy
Demonstrate function of major L.E. nerves
Introduce:
Dermatomes
Myotomes
Sclerotomes
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
We use anatomical constructs in the OR
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
We use anatomical constructs in the OR
Every day !
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
We use anatomical constructs in the OR
Every day !
Surgeons
Anesthesiologists
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
Opx of the Lower Extremity:
Total hip arthroplasty (THA)
Total knee arthroplasty (TKA)
Total ankle arthroplasty (TAA)
Fem-pop bypass graft
Toe amputation
Trans-metatarsal amputation
BKA
AKA
2007 A.D.
Trauma
Tumor
Infection
J. Eric Greensmith, MD, PhD
Practical Anatomy
“What is minor surgery ?”
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
“What is minor surgery ?”
“Someone elses !”
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
What do patients worry about ?
Pain
Disability/mutilation
Risks
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
What do patients worry about ?
Pain
Disability/mutilation
Risks (Death)
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
The good news…
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
The good news…
You won’t die.
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Anesthesiology 2002 97:1609-1617
R.S. Lagrasse
Anesthesia Safety: Model or Myth?
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
The bad news …
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
The bad news …
You will hurt !
2007 A.D.
J. Eric Greensmith, MD, PhD
Results from National Survey:
Postoperative Pain Is Undermanaged
Presence of pain and most intense pain experienced by inpatients
Pain Before Discharge
Slight Pain
Moderate Pain
12%
25%
23%
Pain After Discharge
Severe Pain
Extreme
40%
19%
22%
52%
Apfelbaum JL et al. Anesth Analg. 2003;97:534-540.
2007 A.D.
7%
J. Eric Greensmith, MD, PhD
Postoperative Pain:
We’re not getting much better w/time.
Overall Pain After Surgery
1995
2003
% Adults
Surveyed
50
45
40
35
30
25
20
15
10
5
0
Slight
1Warfield
Moderate
Severe
CA, Kahn CH. Anesthesiology. 1995;83:1900-1904.
JL et al. Anesth Analg. 2003;97:534-540.
2Apfelbaum
2007 A.D.
J. Eric Greensmith, MD, PhD
Extreme
1
2
Practical Anatomy
In a perfect world …
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
Patients wouldn’t:
Hurt
Worry
Suffer
Patients would:
Be safe
Recover quickly
Do better
2007 A.D.
J. Eric Greensmith, MD, PhD
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
“Opiate Sparing”
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
2007 A.D.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
J. Eric Greensmith, MD, PhD
Practical Anatomy
“Opiate Sparing”
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
2007 A.D.
Nausea
Vomiting
Ileus
Pruritis
Mental Status Changes
Addiction potential
Respiratory Depression
? Long-term sensitization ?
? Immuno-suppresion ?
J. Eric Greensmith, MD, PhD
Practical Anatomy
Fool the body into neglecting the injury
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
“Regional Anesthesia”
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
TKA
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
What innervates the knee ?
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
What innervates the knee ?
Dermatomes - skin
Myotomes - muscle
Sclerotomes - bone
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
Dermatomes
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
Dermatomes of the L.E.
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
Myotomes
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
Myotomes
2007 A.D.
J. Eric Greensmith, MD, PhD
Osteotomes
(AKA Sclerotomes)
2007 A.D.
J. Eric Greensmith, MD, PhD
Peripheral Nerves
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
Nerves to the leg:
Lateral femoral cutaneous
Femoral
Sciatic
Obturator
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
Nerves to the leg:
Lateral femoral cutaneous - Sensory
Femoral
Sciatic
Motor & Sensory
Obturator
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
Nerves to the leg:
Lateral femoral cutaneous
Femoral
Sciatic
JOINT NERVES
Obturator
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
Nerves to the leg:
Lateral femoral cutaneous
Femoral
Sciatic
Obturator
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
LFCN
Doesn’t even go to the knee joint !
Why bother with it ?
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
2007 A.D.
J. Eric Greensmith, MD, PhD
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
Nerves to the leg:
Lateral femoral cutaneous
Femoral
Sciatic
Obturator
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
Dermatomes of the L.E.
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
2007 A.D.
J. Eric Greensmith, MD, PhD
2007 A.D.
J. Eric Greensmith, MD, PhD
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
2007 A.D.
J. Eric Greensmith, MD, PhD
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
QuickTime™ and a
decompressor
are needed to see this picture.
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
Nerves to the leg:
Lateral femoral cutaneous
Femoral
Sciatic
Obturator
2007 A.D.
J. Eric Greensmith, MD, PhD
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
Dermatomes of the L.E.
2007 A.D.
J. Eric Greensmith, MD, PhD
Osteotomes
(AKA Sclerotomes)
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
2007 A.D.
J. Eric Greensmith, MD, PhD
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
2007 A.D.
J. Eric Greensmith, MD, PhD
2007 A.D.
J. Eric Greensmith, MD, PhD
2007 A.D.
J. Eric Greensmith, MD, PhD
QuickTime™ and a
decompressor
are needed to see this picture.
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
Nerves to the leg:
Lateral femoral cutaneous
Femoral
Sciatic
Obturator
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
Myotomes
2007 A.D.
J. Eric Greensmith, MD, PhD
Osteotomes
(AKA Sclerotomes)
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
2007 A.D.
J. Eric Greensmith, MD, PhD
QuickTime™ and a
decompressor
are needed to see this picture.
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
Results:
Use knowledge of anatomy
Anesthetize all areas of the leg
Little or no opiate requirement
Little or no general anesthetic requirement
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
Results:
Able to operate on higher acuity pts
Able to send patients home sooner
Safety to patient
Economy to the system
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
JEG
2007 A.D.
J. Eric Greensmith, MD, PhD
2007 A.D.
J. Eric Greensmith, MD, PhD
Excellence
“The quality of a person’s life is in
direct proportion to their commitment to
excellence, regardless of their chosen
field of endeavor.”
Vincent Lombardi
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
I am here to discern, learn, & practice excellence.
I am happy to have you along on this endeavor.
2007 A.D.
J. Eric Greensmith, MD, PhD
Acute Pain Management
“You have to be the change you want to see.”
2007 A.D.
J. Eric Greensmith, MD, PhD
"Divinum est sedare dolorem”
["It is divine to abolish pain"]
2007 A.D.
J. Eric Greensmith, MD, PhD
Thank you
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
Nerves to the leg:
Lateral femoral cutaneous
Femoral
Sciatic
Obturator
2007 A.D.
J. Eric Greensmith, MD, PhD
The
[search for the]
Best Anesthetic
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
“Opiate Sparing”
Anesthesiology: Volume 105(5) November 2006 pp 1016-1023
Modulation of Remifentanil-induced Analgesia and
Postinfusion Hyperalgesia by Parecoxib in Humans
[Pain and Regional Anesthesia]Tröster, Andreas M.D.*; Sittl, Ruth†;
Singler, Boris†; Schmelz, Martin M.D.‡; Schüttler, Jürgen M.D.§;
Koppert, Wolfgang M.D.∥
2007 A.D.
J. Eric Greensmith, MD, PhD
Practical Anatomy
Dermatomes
2007 A.D.
J. Eric Greensmith, MD, PhD
2007 A.D.
J. Eric Greensmith, MD, PhD